Basic Information
| Provider Information | |||||||||
| NPI: | 1891146668 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WOLSIEFER | ||||||||
| FirstName: | JESSICA | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2570 ROUTE 9W | ||||||||
| Address2: | SUITE 10 | ||||||||
| City: | CORNWALL | ||||||||
| State: | NY | ||||||||
| PostalCode: | 125181323 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8452203100 | ||||||||
| FaxNumber: | 8455342940 | ||||||||
| Practice Location | |||||||||
| Address1: | 91 BLOOMING GROVE TPKE | ||||||||
| Address2: | |||||||||
| City: | NEW WINDSOR | ||||||||
| State: | NY | ||||||||
| PostalCode: | 125537757 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8452202074 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2016 | ||||||||
| LastUpdateDate: | 06/02/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 097186 | NY | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | 097186 | NY | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | 090874 | NY | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 04500978 | 05 | NY | MEDICAID |